INTRODUCTION
Palmoplantar pustulosis (PPP) is a psoriasis subtype characterized by small sterile pustules or blisters with hyperkeratosis, erythema, scaling, and fissuring on the palms and/or soles, along with itching and burning sensations.1,2 Histopathological features include epidermal hyperplasia, isolated/distinct intraepidermal pustules, and inflammatory infiltration of predominantly T lymphocytes, neutrophils, and eosinophils.1,2 Although rare, PPP is debilitating, recurrent, and refractory to treatment and thus adversely impacts patients’ physical and psychological well-being.1,2
Current US and EU guidelines offer few specific treatment recommendations for PPP.3-5 Nonbiologic systemic treatment options include acitretin and cyclosporine, which are associated with toxic effects and require frequent laboratory monitoring.3 Various biologic therapies may be recommended,4 but in practice formulary restrictions generally limit options to high-dose anti-tumor necrosis factor-α antagonists.
Tildrakizumab (Ilumya, MK-3222)—a monoclonal antibody targeting interleukin (IL)-23p19—is approved in the US, EU, Australia, and Japan for treatment of plaque psoriasis.6-9 The safety profile of tildrakizumab is very favorable, with low rates of infections, malignancies, and other adverse events of clinical interest.10 This report documents a case of successful tildrakizumab treatment of PPP in a patient with undiagnosed malignancy.
Current US and EU guidelines offer few specific treatment recommendations for PPP.3-5 Nonbiologic systemic treatment options include acitretin and cyclosporine, which are associated with toxic effects and require frequent laboratory monitoring.3 Various biologic therapies may be recommended,4 but in practice formulary restrictions generally limit options to high-dose anti-tumor necrosis factor-α antagonists.
Tildrakizumab (Ilumya, MK-3222)—a monoclonal antibody targeting interleukin (IL)-23p19—is approved in the US, EU, Australia, and Japan for treatment of plaque psoriasis.6-9 The safety profile of tildrakizumab is very favorable, with low rates of infections, malignancies, and other adverse events of clinical interest.10 This report documents a case of successful tildrakizumab treatment of PPP in a patient with undiagnosed malignancy.
CASE REPORT
A 69-year-old woman presented with a chief complaint of severe rash, skin flaking, and skin itching and tenderness, along with a 20-year history of psoriasis. Other history included current smoking, benign adrenal adenoma, medically controlled hypothyroidism, and questionable previously documented diagnoses of rheumatoid arthritis and gluten sensitivity. Prior medications included cyclosporine and prednisone with only temporary improvement and rapid return to baseline symptoms; current medications included levothyroxine. The patient denied any improvement in her psoriasis from previous treatments and had not received any oral or injectable medication for psoriasis for several years at presentation. Her primary care provider had recently referred her for an oncology work-up due to cachexia and smoking history.
On physical examination, the patient had pronounced salmon-pink plaques with silvery scale and scattered pustules, predominantly on her bilateral plantar feet (Figure 1). Skin biopsy revealed histopathological morphology consistent with pustular psoriasis with palmoplantar distribution (ie, PPP). The patient expressed a preference for oral medication
On physical examination, the patient had pronounced salmon-pink plaques with silvery scale and scattered pustules, predominantly on her bilateral plantar feet (Figure 1). Skin biopsy revealed histopathological morphology consistent with pustular psoriasis with palmoplantar distribution (ie, PPP). The patient expressed a preference for oral medication
